The Nursing Process (3 & 4)

What are the 5 Steps in the nursing process?

1. Assessment

2. Diagnostic statement

3. Planning

4. Implementation

5. Evaluation

A good way to remember this by is…?

A.D.P.I.E.

What is it important to remember about the ORDER of the nursing process…?

The order is not linear because assessment never stops.

Nursing Process —> Step 1: Assessment:

It is critical to conduct a comprehensive assessment as this phase will impact the ENTIRE NURSING PROCESS.

• _________ ________ of data related to client’s past and current health status or situation.

• What is the chief complaint (what would ask)?

• Systemic collection

• Priority issue, “What brings you here today?”

Nursing Process —> Step 1: Assessment:

• An assessment database includes what kinds of data?

• What senses would you used when conducting an assessment?

• Both subjective and objective

• Sight, hearing, smell, and touch. (all except taste)

Nursing Process —> Step 1: Assessment:

• What is subjective data?

• What is Objective data?

• Subjective data is what the patient tells you, a verbal description of health concerns

• Objective data are observations or measurements of a client’s health status

Nursing Process —> Step 1: Assessment:

Subjective and Objective data can also be known respectively as what?

• Subjective - symptoms

• Objective - signs

Nursing Process —> Step 1: Assessment:

Validating Data includes two steps leading to an “educated guess” what are they?

a cue and an Inference

Nursing Process —> Step 1: Assessment:

Validating Data:

• What is a cue?

• What is an inference? (can only be validated by asking patient more questions)

• Cue - information nurse obtains through the use of senses (both objective and subjective)

• Inference - nurse’s judgement or interpretation of the cues

Nursing Process —> Step 1: Assessment:

Validating Data:

Give the Cue below as an example, say the inference based on it.

• “I have trouble moving my bowels”

• Blood pressure is 60/50 and client is lightheaded

• Client may be constipated

• Client may have orthostatic hypotension

Nursing Process —> Step 1: Assessment:

Sources of Data:

Name the three sources of data.

• Primary source

• Secondary source

• Tertiary source

Nursing Process —> Step 1: Assessment:

Sources of Data:

• Names the Primary source(s).

• Why would that be the primary source?

• The Client

• Patient is the expert of their own health

Nursing Process —> Step 1: Assessment:

Sources of Data:

• What are the THREE Secondary sources?

• Family and significant others

• Health care team members

• Medical records

Nursing Process —> Step 1: Assessment:

Sources of Data:

• What are the TWO Tertiary sources?

• Relevant literature (like textbooks and studies)

• Nurse’s experience 

Nursing Process —> Step 1: Assessment:

What are the FOUR Data Collection Methods?

• Client interview

• Nursing health history

• Physical examination findings 

• Results of laboratory and diagnostic tests

Nursing Process —> Step 1: Assessment:

• What type of data is collected in a Client Interview?

• What kinds of questions should be asked?

• Subjective data

• open and closed ended questions.

Nursing Process —> Step 1: Assessment:

Which of these examples is an open ended question and which is a closed ended?

• “Do you have any pain right now?”

• “Can you tell me how you’ve been feeling lately?”

• Closed ended question

• Open ended question

Nursing Process —> Step 1: Assessment:

What is a Nursing Health history?

A collection of data of all health dimensions

Nursing Process —> Step 1: Assessment:

What does a Physical Examination Findings include doing? (what kind of data)

A head to toe examination (objective data)

Nursing Process —> Step 1: Assessment:

The last part of the assessment in the nursing process is…?

Organizing / Cluster Data Collection

Nursing Process —> Step 1: Assessment:

A Data Cluster is a group of…?

group of signs or symptoms we group together in a logical way

Nursing Process —> Step 1: Assessment:

Clustering Data can be done using what two models?

• Client Dimensions Mode

• Body Systems Model

Nursing Process - Step 1: Assessment:

What DATA is included in the Data Clustering Client Dimensions Model? (6)

• Physical

• Social

• Spiritual

• Development

• Emotional

• Intellectual

Nursing Process - Step 1: Assessment:

What Physical Dimensions are used for data in the Data Clustering Body Systems Model? (8)

• Respiratory

• Cardiovascular

• Circulatory

• GI

• Neurological

• Genital (inc. Urinary)

• Integumentary

• Reproductive

Nursing Process - Step 2: Diagnostic Statement

Diagnostic Reasoning is…

• Used to inform…?

• A _______.

• Used to inform real-time decision making and communication

• It is a process

Nursing Process - Step 2: Diagnostic Statement

Diagnostic Reasoning is…

• What does it result in?

• Whom does it inform?

• Involves _________.

• Results in diagnostic statements

• Informs appropriate nursing intervention (determines action!)

• involves reflection

Nursing Process - Step 2: Diagnostic Statement

What framework is used as a tool to support diagnostic reasoning?

• How many parts does it consist of?

The R.E.D. Framework

• consists of two or three parts

Nursing Process - Step 2: Diagnostic Statement

What are the three parts to the RED framework?

• R - human Response

• E - Etiology

• D - Defining characteristics

Nursing Process - Step 2: Diagnostic Statement

Based on the R.E.D. Framework what does R stand for and what does it mean?

• What phrase is used following listing your R?

human Response - This is the what? What is the patient’s problem, risk, or strength

• “related to”

Nursing Process - Step 2: Diagnostic Statement

Based on the R.E.D. Framework what does E stand for and what does it mean?

• What phrase is used following listing your E?

Etiology - Answers the why? Why is this response occurring and attributing factors.

• “as evidence by”

Nursing Process - Step 2: Diagnostic Statement

Based on the R.E.D. Framework what does D stand for and what does it mean?

• What is D this proof of?

Defining Characteristics - subjective and objective data

• proof of the human response

Nursing Process - Step 2: Diagnostic Statement

Using RED Framework, provide a diagnostic statement for the following scenario:

• A student comes in saying he has been having frequent headaches and is crying each day. He is very stressed, he also mentions midterms are around the corner, stating he is studying a lot late into the night. This is resulting in the student only getting 5 hours of sleep each night.

Stress related to increased school workload as evidence by sleeping 5 hours per night, frequent headaches, and crying each day.

Nursing Process - Step 2: Diagnostic Statement

Using the RED framework there are THREE types of diagnostic statements that can be made. What are they?

• Three-part statement - (Actual Statement)

• Two-part statement - (Risk for Statement)

• One-part statement - (Wellness)

Nursing Process - Step 2: Diagnostic Statement

Using the RED framework there are THREE types of diagnostic statements that can be made.

• Actual (three part)

• Risk for (two part)

• Wellness (one part)

What parts of R-E-D would each include?

• Actual Statement - human response + etiology + defining characteristics

• Risk For Statement - human response + etiology

• Wellness Statement - ONLY human response

Nursing Process - Step 2: Diagnostic Statement

Using the RED framework there are THREE types of diagnostic statements that can be made. Based on the example below, name the TYPE of diagnostic statement.

• “Risk for injury related to lack of awareness of hazards”

• Risk For Statement (two-part)

Nursing Process - Step 2: Diagnostic Statement

Using the RED framework there are THREE types of diagnostic statements that can be made. Based on the example below, name the TYPE of diagnostic statement.

• “Readiness for enhanced nutrition”

• Wellness Response (one-part)

Nursing Process - Step 2: Diagnostic Statement

Using the RED framework there are THREE types of diagnostic statements that can be made. Based on the example below, name the TYPE of diagnostic statement.

• “Pain related to inflammation in joints (secondary to osteoarthritis) as evidence by client grimacing when ambulating and client verbalizing, “my joints hurt so much”.

• Actual Statement (three-part)

10 Rules for Writing a Diagnostic Statement:

The First rule is to…

1. State a….?

State a human response, not a clients need

10 Rules for Writing a Diagnostic Statement:

The Second rule is to…

2. Start the diagnostic statement with…?

a human response

10 Rules for Writing a Diagnostic Statement:

The Third rule is to…

3. Connect…?

Hint: NOT “due to” or “caused by”

Connect human response to etiology using a “related to”

10 Rules for Writing a Diagnostic Statement:

The Fourth rule is to…

4. Be sure that….?

Be sure that the first two parts aren’t restatements of each other

10 Rules for Writing a Diagnostic Statement:

The Fifth rule is to…

5. Do not mention a…

How ever you can state that is…?

5. Medical diagnosis in the first two parts

• Can state (Secondary to a medical diagnosis)

10 Rules for Writing a Diagnostic Statement:

The Sixth rule is to…

6. Include all factors in…

Include all factors involved in the etiology of human response 

10 Rules for Writing a Diagnostic Statement:

The Seventh rule is to…

7. Select an _______ that can be changed by…?

Select an etiology that can be changed by a nursing intervention

10 Rules for Writing a Diagnostic Statement:

The Eighth rule is to…

8. Avoid judging the….

Avoid judging the client as bad in any part of the diagnostic 

10 Rules for Writing a Diagnostic Statement:

The Ninth rule is to…

9. Avoid suggesting that some member…

Avoid suggesting that some member of the healthcare team is not doing their job.

10 Rules for Writing a Diagnostic Statement:

The Tenth rule is to…

10. Put the CUES that led to diagnosis in…

Hint: /or proof of human response.

the third part (defining characteristics)

Recognizing incorrectly stated nursing diagnostic statements:

Example:

• Impaired comfort; acute pain related to gastritis as evidence by the client saying, “my stomach hurts”

Which rule was broken and why?

Rule 5 - do not mention medical diagnosis in either of the first two parts (gastritis in etiology)

Recognizing incorrectly stated nursing diagnostic statements:

Example:

• Self-care deficit: hygiene related to laziness as evidence by strong foot odor.

Which rule was broken and why?

Rule 8 - avoid judging the client as bad in any part of the diagnostic statement (i.e. laziness)

Recognizing incorrectly stated nursing diagnostic statements:

Example:

• Risk for injury related to insufficient nurse-patient ratio as evidence by 1 nurse for 20 patients.

Which rule was broken and why?

Rule 9 - avoid suggesting that some member of the healthcare team is not doing their job. (i.e.1 nurse for 20 patients)

Nursing Process - Step 2: Diagnostic Statement

Diagnostic Statements for Year one nursing students may include…

• Anxiety, dehydration, constipation, malnutrition, fatigue, insomnia, Pain (be specific - include location)

• Risk for infection, risk for falls, risk for disease

• Optimal self-care, effective stress management, readiness for learning

Based on the involving factors name which types of statement it would be included in.

• Actual Statement - Three part

• Risk for Statement - Two part

• Wellness Statement - One part

Nursing Process - Step 3: Planning

• Is the overarching function of the Planning step in the nursing process?

• What is the product that is produce from the Planning step?

• To develop goals to address the diagnostic statement

• product of the planning phase is a nursing care plan

Nursing Process - Step 3: Planning

There are THREE components of Planning, what are they based on the hint below…?

1. What is prioritized?

2. What is established?

3. What is selected to achieve the goals and expected outcomes?

1. Nursing diagnostic statements

2. Client-centered goals and expected outcomes

3. Nursing interventions

Nursing Process - Step 3: Planning

There is also THREE different types of priorities in the Planning Phase, what are they?

• High Priority

• Intermediate Priority

• Low Priority 

Nursing Process - Step 3: Planning

Based on the priorities in the planning phase…

• High Priority - (Impaired gas exchange)

• Intermediate Priority - (risk for infection)

• Low Priority - (client wants to improve sleep habits)

Give a brief definition of each// how they’re established.

• High - diagnosis that are life-threatening or essential for survival and safety 

• Intermediate - diagnosis involve the nonemergency, non-life-threatening needs of patient

• Low - diagnosis for patients long term health care needs, not always related to illness

What is a Client Centered Short Term Goal?

An objective behavior or response the client is expected to achieve in less than a week or as a stepping stone towards a long-term goal. 

When is a Client Centered Short Term goal most often used?

Immediate client needs (acute care) - (ex. shortness of breath)

What is a Client Centered Long Term Goal?

An objective behavior or response that the client is expected to achieve over a longer period, like several days, weeks or months

When is a Client Centered Long Term Goal most often used?

Used most often for clients at home or in long term care (ex. lose weight)

All Goals must be S.M.A.R.T. meaning…

• S - specific

• M - measurable

• A - attainable

• R - relevant

• T- time-limited 

Example of a SMART goal…

• Client will be able to verbalize three stress management techniques by the end of the 30-minute teaching session

Is it SMART worthy bro?

yeeeee

Nursing Process - Step 3: Planning

When are nursing interventions identified in the nursing process?

Identified during the planning phase of the nursing process

Nursing Process - Step 3: Planning

Nursing interventions is also considered to be?

• what are they based on…?

Overall nursing care

• based on clients needs (goals)

Nursing Process - Step 3: Planning

• Nursing Interventions outline…?…that the nurse performs to achieve the goals and expected outcomes of the client.

• What should nursing interventions be based on?

• outlines actions / activities

• must be evidence based (research findings)

What step in the nursing process initiates or completes planned actions or nursing interventions?

Implementation

Nursing Process - Step 4: Implementation:

The implementation phase of the nursing process involves:

• __________ the client.

• Determining the nurse’s need for…?

• Reassessing the client

• assistance

Nursing Process - Step 4: Implementation:

Within the implementation phase obviously involves implementing the nursing interventions. But, it doesn’t stop there, nurses then need to…

• __________ the delegated care

• And, ___________ nursing activities

• Supervising the delegated care

• Documenting nursing activities

Nursing Process - Step 4: Implementation:

Implementation of Nursing Interventions involves what TWO types of Interventions techniques?

• Direct care interventions

• Indirect care interventions

Nursing Process - Step 4: Implementation:

What is a Direct Care Intervention? (examples)

Treatments that are performed through direct interactions with patients. (ex. changing positions in bed, CPR, teaching)

Nursing Process - Step 4: Implementation:

What is Indirect Care Interventions? (examples)

Treatment or care that is performed away from patient but on their behalf. (ex. documentation, delegation between team members, interdisciplinary collaboration)

Nursing Process - Step 4: Implementation:

There are also different TYPES of nursing interventions, what are the three?

1. Independent Intervention

2. Dependent Interventions

3. Collaborative Interventions

Nursing Process - Step 4: Implementation:

• What is an Independent Intervention initiated by?…

• …Meaning it doesn’t require…?

• Initiated by the nurse

• does not require directions or order from other healthcare providers.

Nursing Process - Step 4: Implementation:

• Independent Intervention def: The nurse acts independently for the care based on…?

• Example of independent intervention?

• evidence that is based on findings and critical thinking

• Teaching side effects of medications

Nursing Process - Step 4: Implementation:

• Dependent intervention is initiated by?

• … to give?

• Physicians or NP initiated

• to give orders or directions 

Nursing Process - Step 4: Implementation:

• What is Direct Intervention aimed to do?

• give an example of direct intervention.

• aimed at treating or managing a medical diagnosis

• administering medication, dressing change

Nursing Process - Step 4: Implementation:

• What is Collaborative Intervention initiated by?

• This means it’s mostly prevalent in…?

• Interdependent (collaboration between health care professionals)

• Therapies or care

Nursing Process - Step 4: Implementation:

• Collaborative Intervention requires…?

• combined knowledge of skills and expertise of numerous healthcare providers

Nursing Process - Step 4: Implementation:

Selection of Nursing Interventions has SIX factors involved that every nurse should consider. What are they?

1. Nursing Diagnostic Statements

2. Goals and Expected Outcomes

3. Evidence base

4. Feasibility

5. Acceptability

6. Capability (competence of a nurse)

Nursing Process - Step 4: Implementation:

Preparatory activities for Implementation include:

• Reassessing the client

• Reviewing and revising the existing nurse care plan

• Organizing resources and care delivery

  • Equipment, Personnel, Environment, Client

• Anticipating and preventing complications

• Implementation skills

  • Cognitive, Interpersonal, and Psychomotor

What do these preparatory activities address?

Addresses the basic needs before intervention

Nursing Process - Step 4: Implementation:

During the ACTUAL implementation of nursing interventions…

• Nursing care activities are delivered to…?

• In most clinical settings ________ ___________ are necessary to achieve selected outcomes.

• meet client centered goals and outcomes

• multiple interventions

Nursing Process - Step 4: Implementation:

What are 7 important skills that nurses can use during the implementation phase?

• Care coordination

• Good time management

• Organization

• Appropriate use of resources

• Priority setting

• Health teaching

• Discharge planning

Nursing Process - Step 4: Implementation:

One of the seven important skills during the implementation phase is “Discharge Planning” - what does this mean?

• Where does it begin?

a discharge plan is used when transitioning a patient from one facility to another

• starts in assessment phase of nursing process

Nursing Process - Step 5: Evaluation

Evaluation is the final step of the nursing process that determines…?

determines the effectiveness of nursing care

Nursing Process - Step 5: Evaluation

The evaluation phase involves 2 Components, what are they?

• Examination of client condition/situation

• Judgement regarding whether change has occurred

Nursing Process - Step 5: Evaluation

In the “Judgement regarding whether a change has occurred” component of the evaluation phase, what does it mean by “change”?

Did the patient meet the goal, partially meet it, or not meet it

Nursing Process - Step 5: Evaluation

• Who is the main source of data in the evaluation process?

• What is important to remember about the evaluation phase during the nursing process?

• The client

• Evaluation happens during the entire process

What are the Five Elements of the Evaluation Process?

1. Identifying evaluation criteria and standards

2. Collecting evaluation data

3. interpreting and summarizing findings

4. Documenting findings and clinical judgement

5. Terminating, continuing, or revising the nursing care plan

What is an important component of each step of the nursing process?

Critical thinking